Prepared by: LCDR Belinda Rand, RN, RNC Neonatal Skin Care Prepared by: LCDR Belinda Rand, RN, RNC

Objectives Name three functions of the skin. Describe two ways in which the skin of a newborn or preterm infant differs from that of an adult. Identify three factors that affect the appearance of the neonate’s skin. Identify two nursing interventions that provide protection for the preterm infant’s skin. Recognize three common skin lesions that are normal variations in the newborn infant. Describe their appearance and treatment, if any. Describe three common vascular lesions in the neonate, their appearance, and appropriate treatment. Identify two syndromes associated with vascular lesions.

Clinical Significance Careful assessment of the skin is an important element of the neonatal physical examination. The appearance of the skin gives the nurse important clues regarding the gestational age, nutritional status, function of organs such as the heart and liver, and the presence of cutaneous or systemic disease. It is important for the RN to be familiar with normal variances in the skin of the newborn infant, as well as those variances that signify disease. Proper care of the neonate’s skin can directly affect mortality and morbidity, especially in the preterm infant. The skin is the first line of defense against infection. Proper skin care can protect the integrity of the skin and prevent breakdown.

Anatomy and Physiology of the skin Three main layers Epidermis: outermost layer, which functions as a barrier from outside penetration. Dermis: directly under the epidermis, 2 to 4 cm thick at birth. Contains blood vessels and nerves that carry sensation; heat, touch, pain, and pressure, sweat glands and hair shafts. Collagen and elastic fibers that connect the epidermis and dermis, and provide the skin with the ability to stretch and return to normal shape. Subcutaneous layer: fatty tissue functions as insulation, protection of internal organs, and calorie storage.

Layers and Structures of Human Skin Insert Figure here

Functions of the Skin Physical Protection Mechanical provides a protective barrier against transepidermal water loss and eternal invasions. Process of sloughing prevents colonization of the skin surface by bacteria and other organisms.

Functions of the Skin Physical Protection Chemical/ bacterial Acidic surface (pH) defends against bacteria and microorganisms Production of melanin protects against damage from UV light radiation.

Functions of the Skin Heat Regulation Sense Perception Production and evaporation of sweat. Dilatation and constriction of blood vessels. Insulation of body by subcutaneous fat. Sense Perception Heat, touch, pain, and pressure.

Differences in Newborn & Preterm Skin Basic structure is same as that of the adult The less mature the infant, the less mature is the functioning of the skin. The earlier the age, the more thin and gelatinous is the skin. Gradual maturing; however, at 4 wks of age a 25 wk infant has twice the transepidermal water loss as a term infant.

Differences in Newborn & Preterm Skin Subcutaneous fat is accumulated predominantly during the third trimester…. Preterm babies have little fat resulting in decreased ability to maintain body temp and blood glucose levels. Brown fat (for temp regulation) begins to differentiate in the 7th month of gestation.

Differences in Newborn & Preterm Skin Newborn skin is thinner and more permeable. Infants, esp. preterm, quickly absorbs topically applied meds and chemicals. Allows for greater insensible water loss in the preterm infant.

Differences in Newborn & Preterm Skin Fewer fibrils connect the dermis and epidermis, & they are more fragile than that of an adult. Risk of injury from tape, monitor, and handling is increased. Ex. Removal of the outermost layer of the dermis with removal of tape or electrodes.

Differences in Newborn & Preterm Skin Sweat glands are present at birth, but full functioning is not present until 2nd/3rd year of life. Newborn has limited ability to tolerate excessive heat. Vasodilatation to increased heat loss can result in hypotension and dehydration, which is attributed to increased insensible water loss.

Care of Newborn Skin Term Newborn Initial bath with water and a mild soap. Soaps containing hexachlorophene have been shown to be absorbed through the skin. Don’t use. Bacteriostatic soap safety has not been established. Use with caution, rinse completely. Parents may want to give the first bath.

Care of Newborn Skin Term Infant Need a stable body temp to bathe Infant (>36.5 C) When stable it is advisable to bathe infant to reduce caregiver’s exposure to blood-borne pathogens. Vernix is good! The vernix caseosa contains large amounts of fats, which protect and insulates the skin, should not be scrubbed off with bath.

Care of Newborn Skin Term Infant Routine use of emollients is not recommended. Creams and lotions contain perfumes and are drying and can irritate the skin. Some products can change the pH of the skin and decrease bacteriostatic properties. Avoid puncturing skin when suspicious of maternal infection.

Care of Preterm Skin Preterm infant Keep skin clean with water, mild non alkaline soap may be used. Handle infant gently and minimally to avoid trauma. Need infrequent bathing to avoid Excessive drying of the skin Avoid over stimulation, Stress and fatigue

Care of Preterm Skin Preterm Infants Minimize the use of tape, removing tape can strip the epidermis. Transparent adhesive dressings can be used for wounds, abrasions, to secure IV’s etc. Safety of adhesive solvents is uncertain, cotton balls soaked with warm water can be used. Increased permeability of the skin allows for absorption of some meds and products; alcohol and betadine; can lead to chemical burns. Wash off well with water.

Care of Preterm Skin Preterm Skin Emollient creams, free of preservatives and perfumes may be of benefit by decreasing transepidermal water loss and skin breakdown when cracking, excessive dryness, or fissures are present. Tent with warm mist may protect the skin and decrease insensible water loss in the very low birth weight infant.

Assessment of Newborn Infant Skin Factors affecting the appearance of the skin Gestational age Postnatal age Nutritional status and hydration Racial origin Type and amount of available light Hemoglobin and bilirubin levels Environmental temperatures Oxygenation status

Assessment of Skin Definitions to describe skin lesions Macule; pigmented, flat spot that is visible but not palpable. Papule; solid, elevated, palpable lesion, with distinct borders > 1 cm in size Plaque; solid, elevated, palpable lesion, with distinct borders > 2 cm in size Nodule; a solid lesion, elevated with depth, up to 2 cm in size

Assessment of Skin Definitions Tumor; solid lesion, elevated with depth > 2 cm is size. Vesicle; elevated lesion or blister filled with serous fluid and < 1 cm in diameter. Bulla; fluid filled lesion larger that 1 cm. Pustule; a vesicle filled with cloudy or purulent fluid. Petechiae; subepidermal hemorrhages, pinpoint in size, that do not blanch.

Assessment of Skin Definitions Ecchymosis; a large area of subepidermal hemorrhage. Wheal; area of edema in the upper dermis, creating a palpable, slightly raised lesion. Ulcer; erosion of skin with damage of the epidermis into the dermis. Will leave a scar after healing.

Common Skin Lesions Normal variations in newborn skin Cutis marmorata Bluish mottling or marbling effect of skin Physiologic response to chilling caused by dilation of capillaries Disappears when infant is rewarmed May be sign of stress or overstimulation in newborn.

Common Skin Lesions Normal Variations Erythema toxicum (Newborn Rash) Small white or yellow pustules surrounded by an erythematous base (redness caused by a histamine release) Differential Diagnosis; may resemble a staphylococcal infection, (confirmed by a smear of aspirated pustules showing increased eosinophils).

Common Skin Lesions Normal Variations Milia Multiple yellow or pearly white papules about 1mm in size; “inclusion cysts”, usually on brow, cheeks, and nose. Observed in about 40% of newborn infants. No treatment needed, resolve spontaneously during the first few weeks after birth.

Common Skin Lesions Normal Variations Epstein pearls Oral counterpart of facial milia. Can be seen on the midline of palate or on the alveolar ridges. Occurs in approx 60% of neonates. No treatment needed.

Lesions from Trauma Forceps marks Red or bruised areas seen over the cheek, scalp, for face of infant following forceps delivery. On assessment look for underlying tissue damage or other signs of birth trauma; scalp abrasions, fractured clavicles, or facial palsy.

Lesions from Trauma Scalp Lacerations May occur during delivery, with placement of scalp electrodes, or fetal blood pH sampling. Treatment consists of keeping the area clean and dry, and assessing for infection.

Lesions from Trauma Intravenous extravasations Vascular access sites in infants should be assessed hourly, evaluate for patency and extravasations. If apparent or if patency is not certain remove IV catheter immediately. If extravasation occurs, elevate extremity. Avoid heat or moist dressings. Topical antimicrobial ointments may aid.

Pigmented Skin Lesions Hyperpigmented macules (mongolian spots) Large macules or patches, gray or blue-green, seen most commonly over the buttocks, flanks, or shoulders. Most common lesion seen at birth, occurring in 90% of black, Asian, and Hispanic babies, in 1-5% of white babies. Due to increased presence of melanocytes dispersed in the dermis.

Pigmented Skin Lesion Cafe’-au-lait spots Tan or light brown patches with well-defined borders. Less that 3 cm in length and less that 6 in number, no pathological significance. 6 or more spots may be an indication of neurofibromatosis (Eichenfield & Gibbs, 2001). Tumors which form on cutaneous nerves & along the thoracic, brachial, and lumbar nerve trunks.

Vascular Lesions Nevus simplex “Stork bite” macular pink areas of distended capillaries found on the nape of the neck, upper eyelids, nose, or the upper lip. They have diffuse borders, blanch with pressure, and become pinker with crying. Tend to fade, but may persist.

Vascular Lesions Port-wine stain Flat vascular nevus, present at birth. Usually pink, may be purple or red. May be small or may cover almost half the body. Flat, sharply delineated, and blanches minimally. Facial lesions are most common. Stains consist of mature capillaries that are dilated and congested directly below the epidermis. Cause not known. Nevus does not grow in area or size. I will not resolve and should be considered permanent. May become darker and thicker.

Vascular Lesions Strawberry Hemangioma Raised, lobulated, soft, bright red tumor located on the head, neck, trunk, or extremities. May occur in the throat, can lead to airway obstruction. Caused by dilated capillaries occupying the dermal and subdermal layers with endothelial proliferation. 20-30% are present at birth, and 90% are evident by w month of age.

Strawberry Hemangioma Usually will increase in size in the first 6 months, then become stable in size before gradual spontaneous regression, most leave no trace. Will take several years. Often there is more than one lesion. Treatment is to allow spontaneous regression. If lesion effects vision, is bleeding, or ulcerating, impinging on other vital functions further treatment should be considered.

Infectious Lesions Thrush Fungal infection of the mouth or throat, caused by Candida albicans, very common in infants. Shows as patches of adherent white material scattered over the tongue and mucous membranes. Treated with oral antifungal preparations such as nystatin (Mycostatin).

Infectious Lesions Candida diaper dermatitis Fungal infection of skin in the diaper area, buttocks, groin, thighs, and abdomen. (check for thrush as well) Caused by organism C. Albicans. Shows as moist, erythematous eruption, often with white or yellow satellite pustules. Treatment is antifungal cream or ointment preparation, nystatin.

Infections Lesions Systemic Candida infection Very low birth weight infants are at risk of having systemic, invasive fungal infections with invasion of the fungus beyond the stratum corneum. Tx: Improve barrier function of the skin by minimizing trauma and maintaining a sterile environment may help prevent onset of illness.

Infections Lesions Herpes Neonatal herpes simplex infection is one of the most serious viral infections in the neonate. Rash appears as vesicular or pustular rash. 70% of infants with herpes will have subsequent rash, but not always before other signs and symptoms of illness develop.

Herpes Absence of rash or vesicles does not eliminate the possibility of disease. Tx: with antiviral agent such as acyclovir should begin immediately. The earlier treatment is begun, the better the outcome (Weston et al.,2002).

References Verklan, M. T., Walden, M., (Eds.). (2005). Neonatal Dermatology. Core Curriculum for Neonatal Intensive Care Nursing. (3rd Ed). Elsevier Saunders. Thureen, P.J., Decan, J., Hernandez, J.A., Hall, D.M. (2005) Assessment and Care of the Well Newborn. (2nd Ed). Elsevier Saunders. Eichenfield, L.F. and Gibbs, N.F.: Hyperpigmentation Disorders. Textbook of neonatal dermatology. Philadelphia, 2001, Saunders, pp. 370-394. Weston, W.L., Lane, A.T., and Morelli, J.T.: Color textbook of pediatric dermatology (3rd ed.). St Louis, 2002, Mosby.